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General NPI Number Information
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NPI Number | 1962781047
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Entity Type | Individual
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Provider Name | JIMMY WAYNE CARPENTER C.PED
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Gender | Male
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Dates
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Enumeration Date | 08/08/2011
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Last Update Date | 08/08/2011
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Provider Practice Location Address
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Address Line | 4500 INDIANA AVE STE 45
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City | WINSTON SALEM
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State | NC
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Zip | 27106-3269
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Country | US
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Telephone | 336-245-4736
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Fax | 888-812-7934
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Provider Business Mailing Address
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Address Line | 4807 EDINBOROUGH RD
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City | GREENSBORO
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State | NC
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Zip | 27406-8322
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Country | US
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Telephone | 336-674-6422
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Fax | 336-674-2282
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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